ROYAL COMMISSION: Infections, maggots and mismanagement of care

Day 3 of the Darwin hearings for the Royal Commission into Aged Care Quality and Safety heard another case study around pressure sores, mismanagement of care and late health treatment which contributed to the death of a 94 year old woman.

Anna Ng fronted the Royal Commission with her evidence of poor care provided to her mother, which contributed to her death. [Source: Aged Care Royal Commission]

A severe pressure wound on Ms Annunziata Santoro had turned black and caused a bone infection, and was later found with maggots inside the wound.

It was found that the facility had waited until Ms Santoro’s General Practitioner (GP) came back from leave, until they took any action. By that point, the injury damage was “irreversible”.

Ms Santoro moved into Assisi Centre Aged Care in Victoria in mid 2017 in a low care ward.

Ms Anna Ng, daughter of Ms Santoro, says she had automatically assumed that her mother would receive good care at Assisi and it wouldn’t be an issue.

Over Ms Santoro’s residency at Assisi, there were many instances of poor care shown through mismanagement of pressure wound healing and constant falls.

Even with assistance from mobility aids and strengthening exercises, the falls kept occurring, with one fall causing a bad fracture to the hip.

Following the big fall, Ms Santoro was admitted to hospital and had staples placed in her hip wound, which were not removed in due course by Assisi and resulted in an infection.

In other problems with Ms Santoro’s health issues, she was losing weight, which didn’t seem to be tracked appropriately, and her medication was changed often, especially after a change of GP.

Dr Eric Tay, Ms Santoro’s new GP, altered the use of psychotropic medication after adverse effects that may have caused an increase in falls.

In the worst case of poor management, Dr Tay returned from leave to head straight into a meeting where the nurse unit manager explained they had found maggots within the heel wound of Ms Santoro.

Mr Tay says in his evidence that he was surprised by the reluctance from staff to provide treatment for Ms Santoro in regards to the maggots and is still stumped as to why they waited for him to return.

Understandably, the family of Ms Santoro were shocked by this finding, which later resulted in her moving into palliative care because it was too late to do anything.

“[The nurse unit manager] went on to say, basically - I’m not saying that it was a good thing, but basically saying that maggots are used in modern medicine, she has used them herself, and was essentially trying to downplay the significance of the whole thing,” says Ms Ng.

“I was appalled that she was essentially not prepared to take any responsibility for what had happened.”

Ms Santoro moved into the Assisi palliative care unit, which Ms Ng described as nothing different from her previous care. Dr Tay suggested Ms Santoro should be moved to a dedicated palliative care facility for appropriate care.

“At this point, my mother’s management had been so poor, her pain management and her care, as I said, I had just completely lost faith. I just wanted her out of there,” explains Ms Ng through tears.

When moved to the new palliative care centre, her quality of care immediately improved for the two days she attended before passing away on October 25, 2018.

In Dr Tay’s evidence, he admitted his reporting was poor in the case of Ms Santoro’s and says it was a good learning experience for himself to be more proactive in seeking medical records from hospitals and providers.

Interim Chief Executive Officer for Assisi Centre Limited, Paul Cohen, admitted that the care provided to Ms Santoro was a cause for concern.

Mr Cohen outlined 13 problem areas that were identified specific to Ms Santoro, including undue waiting times for attention, a failure to remove the hip wound staples until they became infected, unmonitored weight loss, unexplained medication and medication changes, poor wound management, and a failure to manage pain appropriately.

An independent investigator looking into the conduct of Assisi and discovered very serious findings, including that the wound management of Ms Santoro was not effectively undertaken and that there were significant gaps in her care.

Mr Cohen agreed that it was a very concerning report from an independent source, adding that since he joined the organisation he has been implementing updates to Assisi’s policies and practices to reflect good practice.